INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on November 1, 2006.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The facility did not have a full-time clinical supervisor as required.
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Plan of Correction
The position for Clinical Supervisor has been posted on 10/19/06. Program Director is currently interviewing for this position. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
The notice of termination was not documented in one of one client record reviewed, # 9.
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Plan of Correction
Will implement notification of termination form Pamela Van der Laan, Program Director, will conduct in-service with all staff on November 8, 2006. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories did not include information on the family of origin in four of eight records reviewed, # 1, 2, 4 and 6. The employment history was not completed in seven of eight records reviewed, # 1, 2 , 3, 5, 6, 7 and 8.
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Plan of Correction
The Program Director, will conduct in-service with all clinical staff to demonstrate how to make a more detailed composite of a client's family of origin and employment history In-service to be held on 11/8/06. Clinical Supervisor will monitor for compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were missing a composite picture and defense mechanisms in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8. Support systems were not evaluated in seven of eight records reviewed, #2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
The Program Director, will conduct an in-service with all clinical staff to demonstrate how to reflect a historic depiction of defense mechanisms and support systems; such as family, peers, and religion. In-service to be held on 11/8/06. Clinical Supervisor will monitor for compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The frequency of treatment services were missing in eight of eight records reviewed, #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
In-service will be conducted by Program Director, on 11/8/06 to review treatment plans and implement frequency on treatment plans. Clinical Supervisor will monitor for compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Treatment plan updates did not include a review of progress on previously stated goals in six of eight records reviewed, #1, 2, 3, 5, 7 and 8.
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Plan of Correction
In-service will be conducted by Program Director, on 11/8/06 to review treatment plans and include progress updates from previous stated goals. Clinical Supervisor will monitor for compliance. |
709.53(a)(3) LICENSURE Records of Service
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
The record of services were missing the provider(s) of services in six of eight records reviewed, # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
A memo will be issued by Program Director, on 11/8/06 to all clinical staff with a signature page attached informing them to initial off on sessions they themselves facilitated, such a Static Groups and Individual Sessions. Clinical Supervisor will monitor for compliance. |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Verification of work done by the client was not included on treatment plans in five of eight records reviewed, # 2, 3, 4, 5 and 6.
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Plan of Correction
An in-service will be conducted by Program Director, on 11/8/06 for clinical staff. The in-service will cover treatment plans and how one goal should reflect work therapy being a part of each clients' treatment. Clinical Supervisor will monitor for compliance. |